Some time ago, I had a day that was one of those days that makes you really glad your are off today. I swear to god, I had Uncle Jr from the Sopranos as one of my patients, except that my Uncle Jr was in his very elderly and about 95% deaf. The guy was still sharp as a tack, but just…..really….really…. hard of hearing. While a patient in the ED, overall, he was just fine. Now you know how people who are hard of hearing tend to talk louder since they can’t actually hear their own voice? Imagine hearing a patient shouting this the from across the ED

“OH JESUS, JESUS HELP, I KNOW I”M DYING, THIS IS IT, THE LAST FAREWELL, I DON”T WANT TO DIE!.”

The guy is totally fine mind you. So I go see him. And I have to shout back at him, damn near the top of my lungs to get him to hear me. Patient privacy is out the window and in this case as the whole ED is listening.

Me: SIR, YOU ARE NOT GOING TO DIE

UJr: WHADDYA MEAN I’M NOT GOING TO DIE? I KNOW IT, I JUST KNOW IT”

Me: NOT TODAY SIR.

UJr: I”M NOT GOING TO DIE? OH HEY, THAT’S GREAT NEWS! GREAT NEWS! HEY, ARE YOU ITALLIAN? YOU LOOK LIKE A GOOD ITALIAN BOY (keep in mind I am pasty and white with freckles)

Me: WELL SIR, I”M HALF ITALIAN!

UJr: I KNEW IT, I JUST KNEW IT. THANK YOU JESUS! I KNEW THEY’D FIND A GOOD PAESAN TO TAKE CARE OF ME. DO YOU HAVE ANY FRESH TOMATOES I COULD HAVE? I COULD KILL FOR SOME FRESH TOMATOES. OH THANK GOD THERE IS A GOOD PAESAN HERE TO TAKE CARE OF ME

I was hereby referred to as the paesan by the patient for the rest of his time in the ED. 3 hours later, we finally got him on his way home. But not before he shouted a few other gems…

UJr: “HEY PEASAN, I”M GONNA TAKE GOOD CARE OF YOU. WHAT’S YOUR ADDRESS? I”M GOING TO SEND YOU A BIG CHECK WHEN I GET HOME”

Ujr: “NURSE, BRING ME SOME DINNER

Female Nurse: “I’l bring you something to eat soon”

UJr: “I SAID TO BRING ME MY DINNER, RIGHT NOW”

Through and through, the guy was old school Italian and kept us laughing all afternoon long.

Okay, fine, maybe peds is not 100% bad. When you examine a kid, and he crawls across the bed and into your lap and starts trying to auscultate himself with your stethoscope, huge grin on his face, maybe that part is okay.

Being at the children’s hospital for the past few weeks, especially coming off a month of vacation, has been absolute torture. Just…give…me…one…sick…patient! PLEASE! I know that sounds horrible to ask for, but when there are 5 residents covering 13 rooms, and it’s yet another kid with fever, but running around the room like a tornado, it feels like pulling teeth one agonizing patient at a time. The challenge here, and the thing that scares me a little, is that 95% of these kids are totally, absolutely, no doubt about it fine. But some of these other little buggers, there may be some little thing, some little harbinger of impending doom, that if you don’t pick it up, these kids might not do so well. And that’s really no different than adult medicine when you think about it, but still, they are kids, and no one wants to do harm to a 1 year old. So the challenge has been to stay sharp, to do due diligence on each kiddo, get them all undressed, look em’ over from head to toe. Ask all the questions, to each patient, each time, even though, the majority of these kids can be discharged from the doorway.

So last night, I was seeing a 4 year old, mom brought her in for cough and congestion and some dry skin on the face. Clear as day, the kids got a simple URI, but I got the kid undressed anyways, just to make sure she wasn’t retracting or anything like that. And when I did, I noticed two 4cm marks on her forearm.

“Sweetie, what happened to your arm?”

“My mom hit me with a belt!” (all smilely when she said it too). And of course mom is sitting right there. Mom openly admitted to it, giving the reason that she has six kids, lost her cool one day, it only happened once, she feels horrible, and has enrolled in parenting class. Fine. Still gotta fill out my paperwork and call child services.

I’m not trying to say, oh look how great my H&P is, rather, just how easy this would be to miss. I’ve been really trying to do my H&P’s the same for most everyone, adults and kids, regardless of what the complaint is, same set of basic questions, same basic physical exam maneuvers, and then focus and expand based on the complaint, just to make it habit, so when it’s 4 am and I’m dragging my feet, habit will kick in and make me check these things that I might not bother to otherwise, as was the case with this kid.

(plus, the set of questions I ask, hits 10 systems on the ROS, two per system, so that way I’m not actually committing medical billing fraud when I document my level 5 chart! Bonus!)

So I don’t mind if another doctor or nurse disagrees with something I order, or the way I am doing something. That said, there is a proper way that you let a person know that you disagree with them. Usually, it involves being discreet, polite and generally non confrontational about it. Let’s review an example of how NOT to do it…

The patient is a young, non sexually active female presenting with RLQ pain, who was found to have a hemorrhagic cysts on imaging. From across the far side of the ED, where the admitting resident is doing her paperwork.

Admitting Resident: (at loud volume for all to hear). Are you taking care of this patient in bed 12?

Me: Yeah, I’m just signing out the patient now, what can I do for you?

AR: I don’t see on the chart where you documented your pelvic exam (how classy of you to point that out!)

Me: That’s because I didn’t do one

AR: What do you mean you didn’t do one? Why not?

Me: (now getting annoyed, I’m happy to talk about if you think she should have one, but don’t shout it across the ED). Because the patient didn’t need one.

AR: Her urine shows 5-10 white cells which means she might have PID.

Me: Well, as I DID document on the chart, she’s never had sex, which makes that theory impossible, and she has a finding on CT which perfectly explains her urine.

AR: I really think you should do one, as she could have PID.

Me: She’s never had sex, and I’m not about to make my gianormous fingers her first experience.

Me: Fine, well, I’ll just have to do it upstairs then since your are failing to do a thorough assessment here.

(Really? We going to play the passive aggressive game? Okay fine, the ED attending is sitting two feet away, who also happens to be the chief of the department)

Me: Dr. X, the girl in room 12, the medicine team is curious as to why we didn’t do a pelvic exam. She’s never had intercourse, but the medicine team feels her 5-10 white cells on urine dip are indicative of PID, despite that she has no malodorous discharge, dysuria, bleeding or frequency. Do you want me to do an exam on her before she goes up?

Dr. X: She’s never had sex?

Me: She’s denies it up and down

Dr. X: (Turning to the medicine team). We don’t do pelvics in this ED on children who have not had intercourse. What you’re suggesting can be considered sexual assault and battery, so if you’d like to assault your patient, you can do it outside of my department.

Booya! (Fist bumps were had by ED residents all around.)

So that whole situation could have easily been avoided. The medicine resident could have been like “hey, can I ask you something about this patient’s chart?” Which would have piqued my interest, I would have walked over, we could have talked about it, discussed why or why not, I wouldn’t have had to throw her under the chairman’s bus wheels, the nurses wouldn’t have had to comment what a you know what she was when she left, and all would have been well. Just sayin’.

With five minutes left in your shift and your attending is like “Hey, can you go see that nose bleeder in room 2 real quick?”

I think that one of the best things we do in the ICU is when we allow people to die with some degree of peace and respect. We recently had a Cambodian patient, on life support, with no hope of recovery. Discussions were started with family about withdrawal of care. And while they were in support of the idea, their concern was that he somehow had to die at home, and not on a Tuesday. I understand the dying at home part, but I was never clear on what it would be bad for him to be allowed to pass on a Tuesday. It had something to do with his Buddhist religion, but I was never informed of the specific reason. I would have asked all the monks that where there in their orange robes, but none of them spoke English. So when Wednesday morning rolled around, the monks and family gathered in the room, the ambulance crew showed up. We loaded him onto the stretcher and literally pulled the breathing tube out as he rolled out the ICU doors. Medics were instructed to NOT check a pulse, NOT check for breathing, not to do anything other than get him home as quickly as possible. And, under no circumstances, where they to come back to the hospital. It was the best thing we did in terms of patient care all month.

One of the things in medicine that most amazes me, is when a woman chooses to have prophylactic mastectomies. I can only imagine how difficult a decision that must be to make for a woman, or anyone facing a similar choice. I say this as I had a 25 year old patient who had undergone elective bilateral mastectomies a few months ago, and was presenting with breast pain. Now, most of the young people I see in our ED’s, especially the women, for whatever reason, seem to be a good 5-6 years behind on the mental maturity curve. I’m sure the guys are just as far behind, and that’s probably why they don’t bother coming to the ED, haha. But, this woman was different. Maybe she was just innately mature, or perhaps it was having to make such a heavy decision at such a young age that made her grown up fast. Regardless, she was incredibly impressive in her outlook towards her situation, and her life in general, and was true pleasure to be able to treat.

I was in seeing an older couple, probably late 60’s, the wife having come in for chest pain. They were recent immigrants from Turkey, if I had to guess, within the past few years. The husband had a basic grasp of English, but hers was still a work in progress. Culturally, they were still obviously working on acclimating, the husband wearing a bright red, entirely too tight tank top, and leather biker’s cap, on a freezing cold winter day. They were both very pleasant people, trying their best to understand what was happening, but anxious nonetheless, despite multiple reassurances, both very concerned that I was admitting her to the observation unit for a chest pain rule out. Looking back, their anxiety makes sense, I can imagine that in other countries being admitted into the hospital must be a pretty big deal, and probably only happens if you are pretty sick. Not necessarily so in this country, but a topic best discussed elsewhere. After multiple trips into the room to answer all the husbands various questions and to reassure the wife that she in fact was not dying, I noticed that they both were wearing matching necklaces. The necklace was a gold chain attached to a black leather triangle, maybe 3cm at it’s widest point, and it actually appeared to be a pouch of some sort. On my final trip into the room, I couldn’t help but ask about the necklace and what it was. The husband turned to me slowly, and put his finger to his lips is a “shhh” gesture. He leaned in close to me, and whispered in heavily accented english “ Wife and I are exiled Turkish royalty, necklace contains key to safe deposit box. BIG stacks of money”, making a wide gesture with his hands. He must have seen the incredulous look on my face, because he waited a few seconds before him and his wife both broke out laughing. Realizing it was joke, made extra funny given the language barrier, I couldn’t help but cracking up too. He then explained it was a prayer necklace, not in fact a pouch holding a key to untold riches.

I’ve notice among my fellow residency bloggers, that there tends to be significant posting drop off sometime during the second year, and I’ve really tried to not let that happen, but indeed it has. Maybe it’s that not every single thing is all shiny and new anymore, maybe it’s that I like to think about things other than work when not at work, maybe it’s this or that, who knows.

Regardless, time has been chugging along. Hard to believe that I’m more than half way done with residency at this point. This year up to this point, has been pretty great, I have to admit. I feel that I can walk into most any room and have a pretty good idea of what to do. I don’t claim to know it all, by any stretch, in fact, I have a pretty good idea of how high the mountain of knowledge is, still looming above me. But, I feel like it this point, I know how to find the information that I don’t know, if that makes sense. And this has been something I’ve been actively working on, trying to find answers to new problems, problems I may have never have had to consider before, without just asking my attending. I do this intentionally, knowing that when this is all said and done, I’ll probably end up taking a single coverage job is some small ED somewhere, somewhere that might not have a lot of backup readily available.

I’ve seen the way I approach patients change as well, over the past 1.5 years, and over this 2nd year especially. I no longer get frustrated by drug seekers, sickle cellers, gastroparesis and what not. I’ve realized that getting mad, playing bad cop with them, doesn’t actually do anything to fix their problems or relieve their burden on you. Given the wide variety of places they have us work as resident, I’ve seen how many different institutions and doctors have dealt with these types of patients, and are using these as models to develop a strategy that I feel good about personally, while striking a balance between treating the patient and feeding an addiction. “Nasty” patients, still do get under my skin, they still make me mad and frustrated, but I think that’s a good thing quiet frankly. I’d be more worried if these type of people didn’t upset me from time to time.

And yes, I still loathe nosebleeders. I don’t think that’s ever going to change.

I’ve been working in the ICU for the seven days. And 8 days ago, I was actually looking forward to it, which should give you an idea of how bad things were getting downstairs. Like the ED, the ICU has been slammed. The flu has just simply been gumming up the whole hospital, from top to bottom. And unfortunately, it’s led to me witnessing my first medical error. The scary thing is it was not just one, but four, that I can think of, in this past week alone. Going from zero, to four in one week, is kinda worrisome and sobering. One of these errors was directly my fault as well, thankfully to no adverse outcome. I did beat myself up a bit over it, but I’m also pleased with myself in that when I learned of the error, I did the right thing, I alerted the team, my attending, completed an incident report, and even called the patients family to tell them of the error, despite there being no real way they would ever find out about it. That was the hardest part, talking to the family.

At least one of the other errors, unfortunately, may have had much more dire consequences. Nobody was particularly to blame, it was a problem with the systems being overwhelmed rather than negligence, but regardless, it’s still hard to not feel somewhat responsible. When the family asks “What happened, how did we get here?” What are you supposed to say? Thankfully, when they did ask me that, in the middle of the night, I had no idea, at that time, of what had happened, so I wasn’t forced to have to decide to tell the whole truth or just part of it. (not that I would keep it from them, but in such a grave error, I’m sure they would rather have heard about it from an attending, not a resident).

Anyways, I think the flu bug is starting to move on and away, thankfully. I know I am still new to medicine, but this was bad. You don’t need years of experience to know that it’s not supposed to be this way, to read the weary expressions on everyone’s face, to hear the anger in the voices of patients being forced to wait hour after hour, to have that aching tiredness from working hard all day and not really sure if you made actually dent in the problem. It was hard, but as they say, what doesn’t kill us makes us stronger. I hope so.